The ACP Advocate Blog

by Bob Doherty

Wednesday, December 17, 2008

Stimulate this!

If life insurers, automakers, banks, and stockbrokers can get stimulus money from Washington, why not primary care?

Much has been said about primary care being the keystone (as Senator Baucus so aptly described it in his white paper) of a high performing health care system.

Yet we also know that primary care is experiencing death by a thousand cuts. Established primary care practices are struggling to survive. Young physicians in droves are turning to higher paid specialties.

President-elect Obama seems to understand. During the campaign, he observed that "primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation's health. Yet, the numbers of both are dwindling."

When I met with the Obama transition team a few weeks ago, one of his staffers closed with a question, "What could be done in an economic stimulus package to help the economy and lay the foundation for comprehensive health care reform?"

The letter goes on to make the case that the loss of even one primary care practice in a community during these tough economic times will put thousands of patients in the impossible situation of trying to find a new primary care physician, when most of the surviving primary care practices already are at full capacity and unable to take on any new patients.

We know that even a 10% increase in Medicare payments for primary care will not bring primary care earnings up to the point where they are competitive with other specialties, given the wide gaps that currently exist. But it would help struggling primary care practices keep their doors open for the next 18 months. It would also send a signal to medical students and residents that the new administration and Congress are committed to taking an important first step to making primary care an attractive and competitive career choice.

Today's questions: Do you agree that primary care should receive economic stimulus dollars? And how much more do you think primary care would need to be paid to be a competitive career choice?

6 Comments
:

10% Medicare primary care bonus…Hmmmmm… sounds like a squirt gun trying to put out an inferno. A 10% Medicare primary care bonus will not stop the hemorrhage of primary care. By the time a physician has reached the frustration point of leaving practice, a much larger carrot will be needed to persuade them to stay in practice. Leaving practice is a very difficult decision for internists. With that said, over 20% of internists who started their practice after 1990 have left medicine. As for medical students choosing primary care, procedurally based subspecialists still earn 2-5 times more than primary care physicians. No brainer here. 110% primary care salary verses 200-500% primary care salary.

If a bonus was used for primary care, it should be used only with evaluation and management codes as procedures are already relatively well compensated. Isn’t the concept behind the bonus to reward primary care physicians for all the non-reimbursed work they do? In the article “How much time do physicians spend providing care outside of office visits?” Ann Int Med 2007;147:693-698, it was learned that over 20% of time was spent doing patient care outside of an office visit. It is bad enough that E and M codes are already poorly valued; it adds salt to the wound when extra time is consumed for non-reimbursed tasks.

In 2006, Medicare paid out $31 Billion to providers. 99213 payments accounted for 8% of the total budget. Primary care (29% IM, 21% FP, and 3.6% GP) payments for 99213 accounted for 4.3% of the total budget. 99214 payments accounted for 6.8% of the total budget. Primary care (31% IM, 21% FP, and 2.6% GP) payments for 99214 accounted for 3.7% of the total budget. 99215 payments accounted for 1% of the total budget. Primary care (34% IM, 16% FP, and 2.6% GP) payments for 99215 accounted for 0.8% of the total budget. If primary care providers had a 20% increase in reimbursement for codes 99312 and 99214 and a 50% increase in reimbursement for 99215 (this code is definitely under valued) would result in a total Medicare budget increase of 2%.

On a side note, if the big 3 automaker “bail out” failed and that money was directed towards primary care, there would not be a primary care crisis.

A 10% reimbursement hike would perhaps have persuaded me to defer my decision to move into Hospitalist medicine for another 18 months. I was one of those who went against the conventional wisdom in 2002. I went into Generalist IM in 2002 fresh out of IM residency. I bet that my services were needed and would therefore be valued, I was right on the first count, but desperately wrong on the second. Having heard the "help is coming" sermon for the past 6 yrs, I have decided to let brain decide over heart. "Show me the money" is my new mantra.I have taken up a job as a hospitalist and will be moving in to that in January. My patients will not be thrilled, many are scared, I've asked them to write their legislators to rescue primary care, however I am doing what I simply need to do. I've given it a good faith effort. I however will be noone's fool.A sad game is being foisted on physician led primary care in this country. Lets fix that and then we will have reason for a conversation. Until then lets quit with the lip service.

I feel like people are missing half the equation when they talk about the primary care dilemma. It's not only about the money, and it makes us all look bad to intimate as much. It's about the paperwork, the countless hours spent making phone calls and performing other reimbursed services. It's also about the lack of respect afforded to primary care physicians by members within the medical community. They suggest that we can easily be replaced by PAs and NPs. They say that obviously we're not that bright because we chose primary care. We need to start looking at ourselves and change the tone within the medical community. Having all of us fight publicly for a piece of the same pie diminishes us and our profession.

Family Med Resident is so correct. Paperwork and diminished professional respect are an important part of primary care extinction, however, there will not be any discussion about primary care if primary care practices are not financially viable. If an internist has been in a community for about 20-25 years, they would have a practice of about 60+% Medicare patients. I call this the "practice death zone". Medicare reimbursements just cover medical office expenses. Any income comes from the few patients that are personal pay or have private insurance. Typically this income is so meager that a comparable incomed job such as a Wal Mart greeter has better work hours and job satisfaction.

I understand Jay's concern that a 10% bonus is not enough. I think though this needs to be put in a context. The stimulus package is intended only for short-term programs to stimulate the economy, and is not the best vehicle for comprehensive payment reform. ACP's intent is to inject some funds into primary care on an immediate basis as part of the stimulus. The letter makes it clear that this is just a down payment on broader payment reform and that much more will need to be done to make primary care competitive with other specialties. By making the recommendation for funding primary care out of the stimulus, we are also drawing attention to the urgency of the problem and the need to do something, now, to begin to address it.

We decided to recommend that the bonus apply to all services by primary care physicians, not just evaluation and management, because this is simpler for CMS to implement on a short term and immediate basis and would have a bigger immediate on primary care reimbursement. The Medicare Payment Advisory Commission has recommended a much narrower primary care bonus, 5-10% applied only to visit codes.

We also understand that the primary care crisis will need to be addressed in a comprehensive fashion that looks at the paperwork and hassles, poor reimbursement, medical education, debt, the whole enchilada.

ACP's request for a primary care bonus has been picked up by the Wall Street Journal blog, http://blogs.wsj.com/health/2008/12/18/doctors-plead-for-10-medicare-bonus-in-stimulus-package/

Increasing reimbursements will help, but as pointed out in the recent Annals study on why students are not choosing primary care, the problem is much deeper and time is running out. How about pushing for a national network of Patient Centered Medical Homes with local infrastructure to relieve physicians of the burden of dealing with the inefficiencies of private practice fee for service medicine. If physicians do not have to deal with running a small business with payroll issues, collections, insurance forms, 800 numbers etc. they can focus on practicing medicine and find happiness and satisfaction as well as a larger payout for themselves at the end of the month. Jim Webster MD, MS, MACP

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